Nathan W. Kugler

Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis: A Failed Concept

In 2009 Paolo Zamboni et al. implicated that chronic cerebral venous congestion lead to the development of multiple sclerosis. In this review, we examined the role of chronic cerbrospinal venous insufficiency in multiple sclerosis and the proposed therapy entailing venous angioplasty and stenting of extracranial veins with available evidence to date.

Natural history of a postpull pneumothorax or effusion: observation is safe.

BACKGROUND Thoracostomy tube (TT) for drainage of hemopneumothorax is the most common intervention in thoracic trauma. Postpull pneumothorax or effusion (PPP/PPE) is common after removal of a TT. The natural history of PPP/PPE after discharge has not been described. This study evaluates the outcomes and management of PPP/PPE after discharge. METHODS Trauma patients with TT placed from July 1, 2008, to June 30, 2013, were identified from an administrative database and trauma registry. PPP/PPE was defined as the presence of air or fluid in the chest on a postpull imaging. The electronic medical record and final radiology interpretation were reviewed to confirm PPP/PPE during index admission and at discharge. Clinical follow-up and imaging were reviewed for the presence of persistent PPP/PPE. Interventions directed toward PPP/PPE and readmissions were recorded for patients with and without a PPP/PPE. Multivariate logistic regression was performed to identify factors for chest-related readmission. RESULTS Seven hundred ten patients surviving to discharge had a TT placed during the study time frame. Of the 151 patients (21.3%) with documented PPP/PPE on discharge, 115 patients had follow-up data available. Outpatient imaging was obtained in 35 patients, with persistent PPP/PPE noted in 16 patients (45.7%). Six patients (4%) with PPP/PPE at discharge required reintervention. Patients without documented PPP/PPE at discharge had a lower readmission rate (0.7% vs. 6.6%, p = 0.02). Multivariate logistic regression noted the presence of persistent PPP/PPE at follow-up (p = 0.001) to be associated with readmission. CONCLUSION PPP/PPE is a common occurrence following removal of a TT. While patients discharged with PPP/PPE have a statistically higher reintervention rate, the absolute value remains low. This should be considered when treating clinically stable, asymptomatic PPP/PPE. LEVEL OF EVIDENCE Epidemiologic study, level IV.

An update on the currently available nonthermal ablative options in the management of superficial venous disease

BACKGROUND Chronic venous insufficiency affects millions of Americans with symptoms spanning a broad range. Saphenous incompetence resulting in chronic reflux is at the root of most disease and is amenable to surgical correction. METHODS We conducted a systematic review of the literature on nonthermal ablative techniques using a MEDLINE (Ovid) search from January 2000 to August 2016. Only prospective studies and literature review articles in the English language were included for final analysis. RESULTS A total of 358 unique articles were identified, with a total of 60 articles meeting the stated inclusion and exclusion criteria. Historically, nonthermal ablative techniques have not demonstrated clinical results on par with thermal ablative interventions. However, three newer nonthermal ablative techniques have become available for use in the United States. Review of the literature demonstrated significant improvements in nonthermal ablative results, with intermediate-term data suggesting improved durability. CONCLUSIONS Advances in nonthermal ablative techniques have led to a developing role and acceptance in the primary management of varicose veins and venous insufficiency, even in the setting of challenging cases.

Thoracic irrigation prevents retained hemothorax: A prospective propensity scored analysis

BACKGROUND Thoracic trauma resulting in hemothorax (HTx) is typically managed with thoracostomy tube (TT) placement; however, up to 20% of patients develop retained HTx which may necessitate further intervention for definitive management. Although optimal management of retained HTx has been extensively researched, little is known about prevention of this complication. We hypothesized that thoracic irrigation at the time of TT placement would significantly decrease the rate of retained HTx necessitating secondary intervention. METHODS A prospective, comparative study of patients with traumatic HTx who underwent bedside TT placement was conducted. The control group consisted of patients who underwent standard TT placement, whereas the irrigation group underwent standard TT placement with immediate irrigation using 1 L of warmed sterile 0.9% saline. Patients who underwent emergency thoracotomy, those with TTs removed within 24 hours, or those who died within 30 days of discharge were excluded. The primary end point was secondary intervention defined by additional TT placement or operative management for retained HTx. A propensity-matched analysis was performed with scores estimated using a logistic regression model based on age, sex, mechanism of injury, Abbreviated Injury Scale chest score, and TT size. RESULTS In over a 30-month period, a total of 296 patients underwent TT placement for the management of traumatic HTx. Patients were predominantly male (79.6%) at a median age of 40 years and were evenly split between blunt (48.8%) and penetrating (51.2%) mechanisms. Sixty (20%) patients underwent thoracic irrigation at time of initial TT placement. The secondary intervention rate was significantly lower within the study group (5.6% vs. 21.8%; OR, 0.16; p < 0.001). No significant differences in TT duration, ventilator days, or length of stay were noted between the irrigation and control cohort. CONCLUSION Thoracic irrigation at the time of initial TT placement for traumatic HTx significantly reduced the need for secondary intervention for retained HTx. LEVEL OF EVIDENCE Therapeutic Study, Level III.

Early experience using parallel grafting techniques for visceral artery preservation in the treatment of complex aortic aneurysms

Objective: Use of parallel grafting technique for visceral artery preservation is an alternative to prefabricated branched or fenestrated endovascular aortic repair (EVAR) for the treatment of paravisceral and thoracoabdominal aortic aneurysms. We report our early institutional outcomes following the use of “Snorkel” (SnEVAR) and “Sandwich” (San-EVAR) configurations to treat complex aortic aneurysms. Methods: An IRB approved institutional review of the first 13 Sn-EVAR and San-EVAR cases at an academic medical center was performed and immediate perioperative outcomes were examined and analyzed. FDA approved and commercially available aortic endografts and peripheral devices were deployed in all cases. All devices were either delivered via an externalized axillary conduit or femoral artery access. Results: Thirteen consecutive patients were treated using Sn-EVAR or San-EVAR techniques; seven males and six females with mean age of 71.9 years (SD 8.3 years). Eight patients had juxtarenal or pararenal aneurysms requiring primary Sn-EVAR and five had thoracoabdominal aneurysms where San-EVAR technique was used. Three patients had symptomatic aneurysms, one had an inflammatory aneurysm, and one patient had ruptured pathology prior to their repair. The mean aneurysm size was 60 mm (IQR 57-61 mm). Of the preoperatively planned 30 visceral vessel targets, 29 were successfully endografted and preserved (96.7%). No individuals exhibited a type I endoleak, three patients (23.1%) demonstrated type II endoleak, and a single (7.7%) type III endoleaks occurred. Perioperative complications included one MI (7.7%), one ascending aortic dissection with associated stroke (7.7%), one complete T8 paralysis (7.7%), single renal artery dissection (7.7%), and one respiratory failure requiring tracheostomy (7.7%). A single individual (7.7%) required reintervention for retroperitoneal hemorrhage. The 30-day mortality rate was 7.7% with a single death on POD 4 after succumbing to complications of ascending aortic arch dissection noted on POD 1. Conclusions: Initial experience with Sn-EVAR and San-EVAR demonstrates the technique to be a viable “off-the-shelf” alternative for treating complex aneurysms with acceptable perioperative outcomes. Introduction Endovascular repair of abdominal aortic aneurysms (EVAR) has become the standard of care for those with suitable anatomy since its inception in 1991 [1]. In 2005 the EVAR-1 trial was the first major study to demonstrate a 30-day mortality benefit when comparing EVAR to open aortic repair [2]. Subsequently in 2010 the DREAM study confirmed the findings of EVAR-1 while also demonstrating a decreased rate of 30-day major complications [3]. While EVAR has been proven to be a feasible method of repair, 30-40% of individuals remain excluded from EVAR repair due to unsuitable neck anatomy [4-7]. Fenestrated grafts (F-EVAR) were developed as a patient specific means for endovascular repair of patients with renal and/or visceral artery involvement [8]. There are limitations to F-EVAR in that an offthe-shelf system is not yet available with few still under investigative trials. Endograft construction time is required for F-EVAR and urgent and emergent applications are reserved to select physicians who are allowed to construct fenestrations on-table under an FDA approved Investigator Device Exemption. Another approach to complex aortic neck anatomy, endovascular parallel grafting, was first described by Greenberg et al. in 2003 as a complementary technique to maintain visceral perfusion and achieve seal in the setting of a juxtarenal aneurysm [9]. Over the ensuing years this technique has continued to evolve and the spectrum of parallel grafting has expanded to include Snorkel (Sn-EVAR) and Sandwich (San-EVAR) configurations for the treatment of complex aortic aneurysms. We report our early institutional outcomes following the use of Sn-EVAR and San-EVAR techniques for treatment of complex juxtarenal, paravisceral, and thoracoabdominal aortic aneurysms. Methods An IRB approved institutional review of the first 13 planned Sn-EVAR and San-EVAR cases at an academic medical center was performed. Thirty-day perioperative outcomes were analyzed. FDA approved and commercially available aortic endografts and peripheral devices were employed in all cases. All devices were delivered either via Correspondence to: Cheong J. Lee, MD, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA, Tel: 414-805-9160, Fax: 414-805-9170; E-mail: cjlee@mcw.edu Received: September 15, 2015; Accepted: October 16, 2015; Published: October 20, 2015 Kugler (2015) Early experience using parallel grafting techniques for visceral artery preservation in the treatment of complex aortic aneurysms Volume 1(3): 65-69 Glob Surg, 2015 doi: 10.15761/GOS.1000121 femoral access or via creation of an externalized axillary conduit. Imaging evaluation Pre-operative imaging included thoracic and abdominal computed tomography angiography (CTA). This was utilized to define the extent of aneurysm and all visceral vessel involvement while also assessing subclavian and aortic arch anatomy for preoperative planning. Post-procedural imaging included a follow up CTA evaluation within one month along with plans for six month follow-up and yearly thereafter. Patients who had renal insufficiency and were unable to undergo CTA evaluation had duplex evaluation of visceral vessels to assess patency coupled with non-contract CT imaging for graft and aneurysm sac assessment. Procedural technique Procedural technique and overall steps have been previously well described [10-15]. Our technique varies slightly. All thoracoabdominal aortic aneurysms underwent Spinal Fluid Drain (SFD) placement the day prior to operative repair in order to allow pressure monitoring and drainage as necessary. Standard preoperative antibiotics were administered according to SCIP protocol and appropriately re-dosed throughout the case in accordance with pharmacy protocols. All patients were prepped chin to knees and draped to allow bilateral groin and axillary artery access. Systemic heparinization was achieved at the time of axillary and femoral artery access with Activated Clotting Times (ACT) maintained greater than 250 seconds for the remainder of the case. An axillary cut down was performed on either the right or left axillary artery depending on preoperative imaging and planning. The axillary artery was isolated and a 10 mm PTFE graft was sewn in endto-side fashion to the artery providing an externalized conduit for antegrade delivery of endovascular devices. Bilateral femoral artery access was achieved utilizing either a total percutaneous “pre-close” technique or standard femoral cut-down methods as deemed necessary. Only commercially available “off-the-shelf” devices were utilized for the aortic reconstruction. All visceral arteries were preserved utilizing Viabahn (W. L. Gore and Assoc, Flagstaff, Ariz) self-expanding covered stents. Care was taken to ensure adequate overlap of the proximal segment of the Viabahn stent with the proximal margin of the aortic main body. Adequate seal for primary Sn-EVAR repair was possible for patients with a juxtarenal aneurysm with a suprarenal aortic segment of >15 mm below the superior mesenteric artery. A San-EVAR was performed in cases of paravisceral and thoracoabdominal aortic morphology. All patients were started and maintained on dual antiplatelet therapy (aspirin and clopidogrel), if not on preoperatively, Results Thirteen consecutive patients were treated using Sn-EVAR or SanEVAR techniques; seven males and six females with mean age of 71.9 years (SD 8.3 years). Patient demographics including co-morbidities are outlined in Table 1. Four patients (31%) had undergone prior aortic aneurysm repair: two prior open repairs and two prior EVAR repairs. Eight patients had juxtarenal or paravisceral aneurysms requiring primary Sn-EVAR while five patients had thoracoabdominal aneurysms requiring San-EVAR repair. Three patients had symptomatic aneurysms, one patient had an inflammatory aneurysm, and one patient had ruptured pathology prior to repair. The median aneurysm size was 60 mm (IQR 57 mm-61 mm). Of the preoperatively planned 30 visceral vessel targets, 29 were successfully preserved (96.7%). No patients exhibited type I endoleak, three patients (23.1%) demonstrated type II endoleak, and a single patient (7.7%) demonstrated a type III endoleak within the first 30 days. The 30-day perioperative complications and outcomes are summarized in Tables 2 and 3 respectively. Complications include one MI without need for intervention (7.7%), one ascending aortic dissection with associated stroke (7.7%) leading to death, one complete T8 paralysis (7.7%) developing on postoperative day (POD) 16, a single renal artery dissection (7.7%) leading to failed preservation, and one respiratory failure requiring tracheostomy (7.7%). A single individual required reintervention on POD 1 for retroperitoneal hemorrhage successfully managed with coil embolization of a renal artery branch. The 30-day mortality rate was 7.7% with a single death on POD 4 after succumbing to complications of ascending aortic arch dissection noted on POD 1. Follow up CTA obtained within one month demonstrated stable aneurysm sac size in all patients, with a median decrease in aneurysm sac size of 1.5mm (IQR 0.3, 3.8). Discussion Our initial experience with parallel grafting in a high-risk, complex aneurysm patient population demonstrates high technical success with acceptable 30-day mortality and perioperative complication rates. To our surprise, there were no type I endoleaks, and low rates of type III endoleaks. Previous reports on parallel grafting also demonstrate Variable Value Age, mean + SD (range) years 71.9 ± 8.3